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Redo fundoplication in infants and children with recurrent gastroesophageal reflux
M J Wheatley1, A G Coran, J R Wesley
1Department of Surgery, University of Michigan Medical School, Ann Arbor.
Insights
Recurrent gastroesophageal reflux (GER) after Nissen fundoplication affects 12% of children. Redo fundoplication is successful in 80%, but conservative management with gastrojejunal tubes is also a viable option.
Area of Science:
- Pediatric Surgery
- Gastroenterology
Background:
- Nissen fundoplication is a standard surgical treatment for medically refractory gastroesophageal reflux (GER) in children.
- Recurrent GER after fundoplication presents a significant challenge, with reported incidences between 0% and 12%.
Purpose of the Study:
- To evaluate the incidence and management outcomes of recurrent GER following Nissen fundoplication in pediatric patients.
- To assess the effectiveness of repeat fundoplication versus conservative management for recurrent GER.
Main Methods:
- Retrospective review of 286 children undergoing Nissen fundoplication and gastrostomy tube placement between 1974 and 1989.
- Analysis of follow-up data for 242 children, focusing on the incidence of recurrent GER and subsequent treatments.
- Evaluation of outcomes for children treated with medical management, redo fundoplication, or other interventions.
Main Results:
- Twelve percent (29 out of 242) of children developed recurrent GER post-fundoplication.
- Redo fundoplication was performed in 20 children, with 80% achieving successful symptom control.
- Conservative management, including gastrojejunostomy tube feedings, provided symptom control for 11 children.
Conclusions:
- Recurrent GER following Nissen fundoplication is a significant concern, occurring in 12% of cases in this cohort.
- Redo fundoplication offers a high success rate for managing recurrent GER due to wrap disruption or herniation.
- Conservative management with gastrojejunal tube feedings should be considered as an initial approach for recurrent GER.
Abstract:
The Nissen fundoplication is well established as the surgical treatment for medically refractory gastroesophageal reflux (GER) in childhood. Recurrent GER following fundoplication is a challenging problem with a reported incidence ranging from 0% to 12%. From January 1974 to January 1989, 286 children have been treated for GER with Nissen fundoplication and gastrostomy tube placement at the University of Michigan C.S. Mott Children's Hospital; 242 of these children have been followed for an average of 30 months, the remaining 44 have been lost to follow-up. Twenty-nine children (12%) have developed recurrent reflux following fundoplication. Medical management with thickened upright feelings, gastrostomy feedings, or gastrojejunostomy tube feedings has been successful for 11 children with control of reflux symptoms. Five additional children who were treated nonoperatively died of coexistant medical problems within 2 months following documentation or recurrent reflux. The remaining 13 children have required redo fundoplication for wrap disruption or herniation, and an additional six children, initially treated at other institutions, have also undergone redo fundoplications. One other child treated at this hospital required redo fundoplication for a postoperative partial gastric volvulus causing gastric outlet obstruction. Of the 20 children who have undergone a second Nissen fundoplication, 16 (80%) are doing well without recurrent GER. Four children have developed recurrent GER with wrap disruption; 1 is doing well following a third fundoplication, 2 have been managed successfully with continuous feedings via gastrojejunostomy feeding tubes, and a fourth child died of complications related to a recurrent tracheoesophageal fistula. Conservative management with gastrojejunal tube feedings should be considered in the initial management of children with recurrent GER following fundoplication.(ABSTRACT TRUNCATED AT 250 WORDS)